1. Should We Be Doing This? Sealing Dissections: Thoracic Stenting Dr Peter Wilde – Consultant Cardiac Radiologist Dr K Balachandran – Cardiology SpR Mr A Bryan – Consultant Cardiac Surgeon Dr A Baumbach – Consultant Cardiologist Bristol Royal Infirmary

2. Should We Be Doing This? Sealing Dissections Sealing Leaks Closing Aneurysms Repairing Transections

3. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Stanford Type B Dissection (Intramural haematoma)

4. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Aneurysms

5. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Penetrating atherosclerotic ulcer

6. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Transection

7. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Acute or chronic? Acute ( <2 weeks) Recent chest pain Evidence of bleeding Evidence of recent expansion Chronic Slow increase in size Absolute size of aneurysm Mass effects

8. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 What about surgery?

9. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Acute type B dissection Surgical mortality 30-80% Medical treatment mortality 10-15% 20-30% have a complication requiring intervention No clear case for surgery in the majority

10. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Nienaber, Zanetti et al., Am Heart J 2003 Cumulative survival of subacute type B dissection with medical therapy

11. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Thoracic aortic aneurysm resection Elective surgical mortality at least 10% Higher mortality in complex cases Paraplegia rate 5-10%

12. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Acute post traumatic transection Surgical mortality at least 15%, may be much more Associated major trauma, especially head injury Lower incidence of paraplegia

13. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Surgery on the Thoracic Aorta Operations frequently last 5-7 hours Partial cardiopulmonary bypass or circulatory arrest required Prolonged intensive care required Surgeons hate operating on the descending thoracic aorta

14. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Thoracic Aortic Stent Grafting (TASG) First performed in 1994 – immediate clinical benefits there are no controlled trials available yet (INSTEAD)

15. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005

16. Rationale for an INvestigation of STEntgrafts in Aortic Dissection (INSTEAD)-study Hypothesis Should the concept of stent-graft induced aortic remodeling be applied to stable dissection? Mid-term outcomes of stent-graft placement in type B dissection? Improvement of the natural course of type B dissection? Design MC, prospective, randomized Endpoints Outcomes at 1 & 2 years, events, remodeling of aorta

17. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Literature review of TASG (‘meta analysis’) 15 publications 1996 – 2005 632 patients Series from 12 to 110 patients Full range of indications Approx. 30% acute cases Overall early mortality 5.1% Paraplegia only 1.3% ( 0.8% recovered)

18. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Guy’s Hospital Results 1997 – 2005 (Courtesy Dr J Reidy) 143 patients (66% Male) Age 17-90 yr (mean 72) Many non-surgical or poor surgical risk 33% for acute indications Overall 30 day mortality 7.7% 11% acute, 6.2% chronic Paraplegia 4.9% ( 3.5% recovered) Late mortality 15% (mean f/u 34m)

19. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 TASG Indications Traumatic rupture Strong indication for TASG – anatomy usually favourable – long term results? Aneurysm Intervene over 5.5cm assess on a case by case basis according to anatomy Type B dissection Currently only indicated in ‘active’ cases (continuing pain, expansion, bleeding) but…….. Emerging evidence begins to suggest all Type B dissections Penetrating atherosclerotic ulcer Strong indication if bleeding and anatomy is suitable

20. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Nienaber, Zanetti et al., Am Heart J 2003 Medical therapyElective stent graft Cumulative survival of subacute type B dissection: Stent graft v. historical group with medical therapy

21. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Complications of TASG Paraplegia Stroke Vascular complication (femoral/iliac) Device migration Endoleak Type 1 – marginal leak Type 2 – external collateral filling Type 3 - Device leak/failure

22. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Technical aspects of TASG (Bristol) High quality imaging is essential for planning Preliminary high resolution CT angio 3D reconstruction for assessment of anatomy and measurements Evaluate vascular access Aortograms during procedure in chosen projection

23. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Technical aspects of TASG (Bristol) Catheter laboratory environment General anaesthesia (blood pressure and heart rate control) 25F devices - surgical access (combined surgery/interventional team approach) Y-graft approach Additional right radial catheter for check angios Have CSF drainage as an available option

24. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005

31. Case 1 BK 27 y Female RTA Severe injuries including multiple pelvic fractures in external fixation

32. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005

37. BK follow up Well and leading a normal life 1 year later

38. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Case 2 AE 81 y Male Mycotic aneurysm (salmonella) of descending thoracic aorta with haemoptysis and dysphagia Previous CABG

39. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005

44. AE follow up Well and leading a normal life 2 years later (oral antibiotic prophylaxis)

45. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Bristol Experience 2002-2005 11 patients (7 male) Age 27-81 yr (mean 63) 4 chronic aneurysm 3 type B dissection (2 Marfan) 2 traumatic rupture 1 haemorrhagic ulcer 1 mycotic aneurysm 1 failed deployment (vascular access) No early mortality, 1 late mortality (9 mths ? cause) CT follow up so far in 8, no endoleaks 1 transient paraplegia (treated CSF drainage) 1 transient renal failure (trash embolisation)

46. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 What do we need to do this? Most importantly a committed team who are prepared to work together Radiology and/or cardiology, cardiac surgery and/or vascular surgery, anaesthesia, cath lab team, operating theatre team High quality imaging Institutional commitment Financial support, clinical governance support (new techniques) Time To learn the technique (visits etc.) To organise each case (small numbers, high complexity) Facilities Cath lab/ vascular angio lab (of operating theatre standard) or operating theatre (very high quality image intensifier)

47. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Should we be doing this? Yes definitely but….. A lot of planning is required Protocols for indications and technique required Good access to high quality imaging Funding issues are substantial

48. P Wilde - BCIS Autumn Meeting Bristol – 30 th September 2005 Call yourselves interventionists? This is a REAL stent!